The sex lives of seniors

As soon as she wakes up, Helen Goldenberg lines up her pills: 23 of them that she takes in four bouts over the course of the day. First she takes her acid reflux pill, then the pills that control her blood pressure. After breakfast, she takes her HIV pill: a big blue tablet to keep the virus in check. Goldenberg is 66 years old, and this year marks her third decade of living with HIV.

Sexually transmitted infections, including HIV, are often conflated with youth. But more people, like Goldenberg, are living with HIV into their 60s and 70s thanks to a cocktail of medications that have drastically improved survival.

Thirty-one percent of HIV-positive Americans are 50 or older, according to the government’s Administration on Aging. By next year, that number is estimated to jump to 50 percent.

Not only are people living longer with HIV, they’re becoming infected later in life. While navigating the screen on her iPhone, Goldenberg lists three close friends in Dallas who are in their 50s and 60s and who were recently diagnosed with HIV. One of them tested positive at the age of 69.

Rates of sexually transmitted infections, including HIV, have increased in the over-65 age group in recent years. Syphilis infections have gone up 52 percent and chlamydia infections by 31 percent from 2007 to 2011, according to the Centers for Disease Control and Prevention.

In Texas, the rate of new HIV diagnoses in people over the age of 55 has been consistently higher than the U.S. average since 2008.

Older people are having sex. Lots of sex. And some of it is the unprotected kind that puts them at risk for sexually transmitted infections. It seems that we’re uncomfortable talking about the sex lives of older adults.

Even the World Health Organization in a recent report confessed to collecting sexual health data only for people up to the age of 49. The false assumption that physical intimacy declines at age 50 isn’t limited to the medical establishment — it’s common throughout society.

Assumptions are dangerous, and denial can fuel epidemics. A society ambivalent to the sexual health needs of older people is far removed from reality. Doctors who assume that their older patients are not sexually active are denying them the sexual health information that could save their lives.

Dr. Louis Sloan isn’t so bashful. At his clinics in downtown Dallas and near NorthPark Center, the infectious diseases specialist makes sure that sexual health information is available for the entire spectrum of his patient population.

Sloan is especially concerned about the number of older patients who are presenting with primary syphilis, a bacterial infection that is often asymptomatic. Diseases that don’t cause symptoms can go undiagnosed for a long time if a person isn’t having regular sexual health check-ups.

That’s a problem because having one sexually transmitted infection puts you at risk of getting another one — especially HIV. Lesions, like the ones caused by syphilis and herpes, are easy entry points for the virus, and inflammation caused by other sexually transmitted infections also facilitates transmission of HIV.

Moreover, people already living with HIV are five times as likely to transmit the virus when they’re infected with another sexually transmitted infection. Syphilis isn’t the only sexually transmitted infection that’s going undiagnosed for long periods of time — it’s estimated that 1 in 5 Americans with HIV aren’t aware of their status.

That number could be even higher for older adults. Only 22 percent of women and 38 percent of men over the age of 50 said they had discussed sex with their doctor, according to the government’s National Social Life, Health and Aging Project. If doctors aren’t considering that their older patients are having sex, they’re less likely to test them for sexually transmitted infections or refer them to specialists like Sloan.

It may also explain why older adults with HIV are more likely to be diagnosed with late-stage disease than younger adults. That can make it harder to treat the virus and leaves them open to passing on the virus unknowingly.

While older adults are less likely to have multiple sexual partners than young people, the majority are sexually active. Sloan says high divorce rates and the increasing number of people living longer with HIV are contributing to the rising rates of infection.

Some senior centers in the Dallas-Fort Worth area are struggling with the idea that their clients are having sex. Ann Wilder, a social worker at the University of North Texas who specializes in the well-being of older adults, approached a string of well-known senior centers and asked if she could discuss the issues of sexual health, sexuality and dating in older adults. Her request was met with a resolute “no.” One director eventually agreed to talk to her, but only if she could remain anonymous.

Their reticence to discuss the issue halted Wilder’s graduate research on the sexual health of older adults. (She’s studying the living arrangements of older adults in India instead.) But her colleague, Dr. Iftekhar Amin, had another idea. He accessed government data from a nationwide survey on societal change and used that to study the sex lives of older adults.

He found that nearly three-quarters of sexually active people over the age of 55 were engaging in sexually risky behavior like not using condoms during sex. Older women, in particular, were less empowered to negotiate safer sex in their relationships. Amin found that many stopped using condoms after menopause, indicating that birth control, rather than infectious diseases, had been their priority.

Vulnerability to sexually transmitted infections actually increases as we age. For women, the lining of the vagina thins and offers less protection against viruses and bacteria. In both sexes, the immune system slows so that the body is less resilient in its fight against microbes.

In addition to biology, Amin says society’s archaic perception of older adults and sexuality is to blame for the rising rates of sexually transmitted infections in the over-55 age group. “We have all of these statistics out there, but no one’s really talking about the issue,” he says. “It’s as if people just don’t want to consider that their grandparents are having sex.”

But today’s grandparents are children of the sexual revolution — a revolution that’s often credited with the advent of the contraceptive pill. The sexual education that they received as young people in the 1960s and 1970s was focused more on birth control and biology and less on infectious diseases.

The next wave of sexual health education came in the 1980s, with the devastation of the AIDS epidemic. Those early AIDS campaigns were mainly targeted at young gay men; many people, now in their 60s or older, felt that AIDS education was not meant for them, especially women. That was the case with Goldenberg. “Me and my girlfriends didn’t think AIDS was something that could happen to us. I was living in San Francisco back then, but AIDS was something that happened to other people, not us women.”

At a May conference in Dallas, Goldenberg will share her story with more than 200 HIV-positive women from across North Texas. She hopes her speech at the Legacy Grace conference will offer them strength and hope.

In 1984, Goldenberg was living in San Francisco and working her way up the corporate ladder. A hard-working vice president at Bank of America, it was a cup of scalding coffee that led her to the doctor’s office. She thought the coffee was to blame for the crop of blisters that had sprouted on her tongue seemingly overnight. Her doctor thought otherwise. He had lost countless patients to AIDS in the last three years; with one look at Goldenberg’s tongue, he told her she had AIDS. The lesions on her tongue weren’t caused by hot coffee, he said; they were caused by oral thrush — a fungal infection that often results from a weakened immune system — and is a sign of AIDS.

Goldenberg refused to believe him. She thought he was “jumping on the [AIDS] bandwagon like every other doctor in town.” Then three years later, just months before she planned to marry her boyfriend of four years, Goldenberg’s soon-to-be mother-in-law casually mentioned that her son had “full blown AIDS.” She asked Goldenberg, “Do you have it too?” Goldenberg went for a blood test and called off the wedding. Then she moved to Dallas.

Goldenberg recalls family members who stopped sharing plates and silverware with her after they heard the news. They warned her not to speak about her status. “My family said that was like washing dirty laundry in public,” she says. But now she is a prolific public speaker and even an actress. At last year’s conference, Goldenberg acted in a play about four women — two young and two old — who were diagnosed with HIV.

At this year’s conference, more than a third of the audience will be HIV-positive women aged 50 or older. Melissa Grove, executive director of the Legacy Counseling Center and organizer of the conference, says that proportion is increasing each year.

At the Legacy Counseling Center near Cole Park, more women over the age of 50 are seeking support with new HIV diagnoses. “There’s not really anywhere else for them to go,” says Grove.

Besides tackling new medication regimens and the side effects that come with them, older adults diagnosed with HIV are dealing with the stigma that still surrounds the virus. “A lot of our clients are feeling fear, shame and confusion,” says Grove. “Usually, they haven’t heard much about HIV/AIDS before their diagnosis, and they are so scared to tell anyone about what they’re going through.”

Goldenberg agrees that even for her, an approachable woman with a broad smile, reaching out to other women — especially older women — can be difficult. “Some of these women are scared to meet me!” she exclaims. “We have to meet at McDonald’s or someplace that is definitely not associated with HIV.”

Finding safe spaces to share personal stories and establishing support networks is beneficial for both physical and emotional health. For older adults, good social support actually offers protection from sexually transmitted infections, according to Amin, the University of North Texas researcher.

Seniors who were socially engaged — those who volunteered at local organizations or were involved with community groups — were less likely to have unprotected sex compared with those who were less socially active, Amin found in his study. He says that’s because socially engaged seniors have better access to sexual health information.

Staying active and informed helps older adults protect themselves from the increasing rates of sexually transmitted infections in their peer group. But the public health problem isn’t that older people are having sex. It’s that the rest of us are so shocked by it.

Dr. Seema Yasmin, who served as a disease detective at the Centers for Disease Control and Prevention, is a fellow in global journalism at the University of Toronto’s Munk School of Global Affairs. Her email address is drseemayasmin@gmail.com. Follow her on Twitter at @DoctorYasmin.

Correction: An earlier version of this essay misstated the location of senior centers visited by social worker Ann Wilder. They were not in Dallas.

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